Corporate Compliance Program Prepared With Assistance Of Grassi Healthcare Consulting

Transcription

1 Corporate Compliance Program Prepared With Assistance Of Grassi Healthcare Consulting Table of Contents Page 1

2 Table of Contents Provider Information... 4 Preamble... 5 Board Approval... 7 Compliance Program... 8 Required Elements of the Compliance Program... 8 Definitions Designated Employees with Vested Compliance Responsibility Code of Conduct Policies Policy Compliance Responsibilities Compliance Committee Corporate Compliance Officer & Deputy Compliance Officer Responsibilities of Program Directors and Managers Policy Compliance Training and Education Policy Compliance Communication Policy Investigating Compliance Concerns Policy Non-Retaliation, Non-Retribution, and Non-Intimidation for Reporting Policy Disciplinary Action & Sanctions Policy Credit Balances and Overpayments Policy Response to Governmental Inquiry Policy Prohibition Against Employing or Contracting with Ineligible Persons Policy Conflicts of Interest Policy Acceptable Use and Social Media Policy Retention of Certain Records Forms COMPLIANCE PROGRAM ACKNOWLEDGEMENT OF RECEIPT... Error! Bookmark not defined. STANDARD COMPLAINT FORM COMPLIANCE PROGRAM REPORTIN FORM 46 ANONYMOUS REPORTING FORM COMPLIANCE PROGRAM INTERNAL INVESTIGATION FORM.48 NOTICE OF COMPLIANCE TO VENDORS LETTER TO CLIENTS ON FRAUD AND ABUSE Relevant Law Table of Contents Page 2

3 Confidentiality and HIPAA requirements and HITECH rule False Claims Act (31 USC ) Administrative Remedies for False Claims (31 USC Chapter ) New York State Laws NY False Claims Act (State Finance Law, ) Social Services Law 145-b False Statements Social Services Law 145-c Sanctions Social Services Law 145, Penalties Social Services Law 366-b, Penalties for Fraudulent Practices Penal Law Article 155, Larceny Penal Law Article 175, False Written Statements Penal Law Article 176, Insurance Fraud Penal Law Article 177, Health Care Fraud Whistleblower Protection Federal False Claims Act (31 U.S.C. 3730(h)) NY False Claim Act (State Finance Law 191) New York Labor Law New York Labor Law Table of Contents Page 3

4 Provider Information Name of Medicaid Provider: Osborne Treatment Services, Inc. Provider Address: 809 Westchester Avenue, Bronx, NY, Chief Compliance Officer: Patricia Ritchings Anonymous Ethics Hotline: Provider Information Page 4

5 Preamble MISSION STATEMENT The Osborne Association, Inc. and affiliates ( Osborne or the organization ) offers opportunities for individuals who have been in conflict with the law to transform their lives through innovative, effective, and replicable programs that serve the community by reducing crime and its human and economic costs. Since 1931, Osborne has offered opportunities for reform and rehabilitation through public education, advocacy, and alternatives to incarceration that respect the dignity of people and honor their capacity to change as they achieve selfefficiency, adopt healthy lifestyles, enter the workforce, form and rebuild families, and rejoin their communities. PURPOSE Osborne is committed to conducting its business activities in full compliance with all federal, state and local laws and regulations, and recognizes that failure to comply could threaten the organization s continuing participation in government health care programs. Therefore, the Audit/Finance Committee of the Board directs the Chief Compliance Officer to undertake this Compliance Program in order to continue its commitment to high standards of conduct, honesty and reliability in its business practices. This Corporate Compliance Program is intended to provide reasonable assurance that we conduct business activity in a compliant manner while exhibiting our commitment to promoting prevention and detection of health care fraud and resolution of instances of potential misconduct within our day-to-day operations. The Goals of Osborne s Corporate Compliance Program include: Ensuring that federal and state regulations are enforced and third party guidelines are followed, including those from health insurance companies; Avoiding coding or billing which violates Medicaid rules or regulations or other federal rules or regulations; Avoiding intentionally or knowingly making false or erroneous entries on reports, participant charts or other relevant records; Reporting known or suspected violations of law, regulation, Osborne s organizational policy or Code of Conduct to the Compliance Officer; Providing a common understanding of expectations for proper conduct; Providing an effective process for Employees to ask about compliance related concerns and for management to address those concerns; Providing a framework for dealing with difficult, complex, or confusing issues such as interpretation of regulations or ethical concerns; Ensuring that appropriate individuals will participate in investigations and provide solutions to prevent future occurrences of alleged violations; Providing for annual Compliance training as required; Avoiding unauthorized alteration or destruction of the records of participants or the organization; Preamble Page 5

6 Avoiding behavior detrimental to the operation of the organization. Applicability. The Compliance Program is intended to be a routine part of the organization s operations. All Affected Individuals are required to comply with the Code of Conduct contained in this manual and all other policies included in the Compliance Program. All Affected Individuals are further expected to use their best efforts to prevent, detect and correct any fraud, abuse or waste in connection with federally funded health care programs and private health plans. The Corporate Compliance Program Manual will be accessible to all Affected Individuals via Osborne s website and agency intranet. Hiring Package. All new Employees shall be provided a Compliance Program package by the Human Resources Department containing, at a minimum, a summary of their responsibility to be personally and professionally responsible for understanding and carrying out the Code of Conduct and the policies contained within the Compliance Program. All new Employees are required to complete the attached form acknowledging receipt of these materials. Preamble Page 6

7 Board Approval At a regular meeting of the Board of Directors of The Osborne Association, Inc. on March 15, 2017, after proper notice and upon motion duly made, seconded, and passed, this updated Corporate Compliance Program was adopted. (A copy of Osborne Board Meeting minutes for the March 15, 2017 meeting is on file with Osborne s Compliance Office). Board Approval Page 7

8 Compliance Program Required Elements of the Compliance Program Osborne s Compliance Program ( Compliance Program ) shall have, at minimum, the following eight elements: 1. Written Policies and Procedures. a. The Compliance Program shall include a set of written policies and procedures that describe compliance expectations in a code of conduct or code of ethics. b. The Compliance Program shall include or reference the formal resolution of the Board documenting that Compliance Program has been adopted and implemented. c. The policies contained within the Compliance Program shall provide direction to Employees and other Affected Individual with regard to potential compliance issues. d. The policies contained within the Compliance Program shall provide direction on how to communicate compliance issues to appropriate compliance personnel. e. The policies contained within the Compliance Program shall provide direction on how potential compliance problems are investigated and resolved. 2. Designated Employee with Vested Compliance Responsibility. a. The Compliance Program shall designate an Employee vested with responsibility for dayto-day operation of the Compliance Program ( Compliance Officer ). b. The Compliance Program shall require the Compliance Officer to report directly to the organization s chief executive or other senior administrator. c. The Compliance Program shall require the Compliance Officer to report to the governing body about the activities of the Compliance Program, and shall define the frequency of such required reporting. 3. Training and Education. a. The Compliance Program shall require training and education to be provided on compliance issues, expectations and the compliance program operation. b. Compliance training and education will be provided to: i. All employees ii. All executives iii. All governing body members c. The Compliance Program shall require this training to recur periodically, and shall define the frequency of recurring training d. The Compliance Program shall require this training to be part of orientation for the following: i. New employees ii. Executives iii. Governing body members 4. Communication With Compliance Officer a. The Compliance Program shall include policies that establish lines of communication to the Compliance Officer that allow for compliance issues to be reported. b. The lines of communication established by (a) shall be accessible to: Compliance Program Page 8

9 i. All employees ii. Vendors and volunteers iii. All executives iv. All governing body members c. The Compliance Program shall establish a method for anonymous and confidential good faith reporting of potential compliance issues as they are identified for each group identified in (b) above. 5. Disciplinary Policies to Encourage Good Faith Participation a. The Compliance Program shall establish disciplinary policies to encourage good faith participation in the compliance program by all Affected Individuals, as appropriate based on their role. b. The disciplinary policies established pursuant to (a) above shall include the following with respect to all Affected Individuals, as appropriate based on their role: i. Expectations for reporting compliance issues ii. Expectations for assisting in the resolution of compliance issues iii. Sanctions for failing to report suspected problems iv. Sanctions for participating in non-compliant behavior v. Sanctions for encouraging, directing, facilitating or permitting non-compliant behavior. c. The Compliance Program shall require the fair and firm enforcement of these disciplinary policies. 6. Routine Identification of Compliance Risk Areas a. The Compliance Program shall establish a system for routine identification of compliance risk areas specific to the organization. b. The Compliance Program shall establish a system for self-evaluation of the risk areas identified by the risk identification process, including internal audits and, as appropriate, external audits. c. The Compliance Program shall establish a system for evaluation of potential or actual non-compliance as a result of these self-evaluations and audits. 7. Responding To Compliance Issues a. The Compliance Program shall establish a system for responding to compliance issues as they are raised, including: i. Investigating potential compliance problems ii. Responding to compliance problems as identified in the course of selfevaluations and audits iii. Correcting compliance problems promptly and thoroughly iv. Implementing procedures, policies and systems as necessary to reduce the potential for recurrence b. The Compliance Program shall establish a system for identifying and reporting compliance issues to the NYS Department of Health or the NYS Office of Medicaid Inspector General, including the refunding of Medicaid overpayments. 8. Non-Intimidation and Non-Retaliation Policies a. The Compliance Program shall include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including but not limited to: Compliance Program Page 9

10 i. Reporting potential issues ii. Investigating issues iii. Self-evaluations, audits and remedial actions iv. Reporting to appropriate officials as provided in Sections 740 and 741 of the New York State Labor Law (see section entitled Relevant Lawlater in this Manual). Compliance Program Page 10

11 Definitions Affected Individuals Compliance Office Employees Executives Financial Interest Governing Body Members Ineligible Person Interested Person Executives, officers and governing body members and other employees. This includes the President/CEO, executive management, program directors and managers, supervisors and any other persons or individuals hired by and in the paid service of the organization. Also included are temporary and contract employees and, where practical, independent contractors doing business with the organization. The Chief Compliance Officer, together with any Deputy Compliance Officer that may be appointed All full-time and part time employees, including executive management, program directors, supervisory, managerial and administrative personnel. Employees with the ability to make decisions and set policy for the organization A person has a financial interest if the person has, directly or indirectly, through business, investment, or family relationship: a. an ownership or investment interest in any entity with which the Corporation Organization has a transaction or arrangement, b. a compensation arrangement with the Corporation Organization or with any entity or individual with which the Corporation has a transaction or arrangement, or c. a potential ownership or investment interest in, or compensation arrangement with, any entity or individual with which the Corporation Organization is negotiating a transaction or arrangement. Compensation includes direct and indirect remuneration as well as gifts or favors that are not substantial in nature. A financial interest is not necessarily a conflict of interest. A person who has a financial interest may have a conflict of interest only if the appropriate Board or committee decides that a conflict of interest exists. All Board members An individual or entity who/which has been excluded, suspended, debarred or otherwise deemed ineligible to participate in a federally funded healthcare program and has not been reinstated after a period of exclusion, suspension, debarment or ineligibility. Any director, principal officer, or member of a committee with Board delegated powers who has a direct or indirect financial interest, as defined below, is an interested person. Compliance Program Page 11

12 Designated Employees with Vested Compliance Responsibility The following personnel have been designated as employees with vested responsibility for the implementation and operation of the Compliance Program at the organization. The responsibilities of the designated employees are described in the Policy section of this manual under Compliance Responsibilities. Chief Compliance Officer: Patricia Ritchings Acknowledgement:, Chief Compliance Officer Date: Deputy Compliance Officer: Acknowledgement:, Deputy Compliance Officer Date: Compliance Program Page 12

13 Code of Conduct A. Introduction Osborne s compliance program embodies its commitment to conducting business in compliance with all applicable laws, rules, regulations and other directives of the federal, state and local governments and agencies. Our commitment is to adhere to the code of conduct ( Code of Conduct ) set forth below, which is applicable to all Affected Individuals. The Code of Conduct is intended to provide general guidelines to assist employees to understand and appreciate the manner in which Osborne wishes to conduct business. Although the Code of Conduct can neither cover every situation in the daily conduct of our many varied activities nor substitute for common sense, individual judgment or personal integrity, it is the duty of every Staff Member to adhere, without exception, to the principles set forth herein. More complex aspects of the Code may require additional guidance and direction (See Section V. of Osborne Employee Handbook). The Code of Conduct shall be distributed upon hire, to all employees. Employees are responsible for ensuring that their behavior and activity is consistent with this Code of Conduct. This Code is not intended to cover every situation which may be encountered and employees should comply with all applicable laws and regulations whether or not specifically addressed in the Code. B. Compliance with Laws and Regulations It is the duty of Osborne and its Employees to comply with all applicable federal, state and local laws, rules, regulations and standards ( laws and regulations ). Each individual must be aware of the legal requirements and restrictions applicable to his or her respective position and duties. While the duty remains the responsibility of each individual, Osborne shall implement programs necessary to foster further awareness of applicable laws and regulations and to monitor and promote compliance with such laws and regulations. Any questions about the legality or propriety of any actions undertaken by or on behalf of Osborne should be referred immediately to the Compliance Office or to the CEO. C. Fraud and Abuse Osborne expects its employees to refrain from any conduct which may violate applicable federal and state laws and regulations, with special emphasis on those related to fraud and/or abuse. These laws generally prohibit: (1) the transfer of anything of value in order to induce the referral of participants or any government program business (i.e., Medicare, Medicaid and other federal or state health care programs); and (2) the making of false representations or the submission of false, fraudulent or misleading claims to any government entity or third party payer, including claims for services not rendered, claims which characterize the service Compliance Program Page 13

14 differently than the service actually rendered, or claims which do not otherwise comply with applicable program or contractual requirements. More specific guidance with respect to laws and regulations applicable to fraud and abuse can be found elsewhere in this manual under the section entitled Relevant Law. D. Professional and Ethical Standards As professionals, all employees have a duty to support Osborne s goals to provide services of the highest quality that respond to the needs of our participants. The services provided must be reasonable and necessary for the care of each participant, and such care must be provided by properly qualified individuals. All such care must be properly documented as required by law and regulation, payer requirements, professional standards and Osborne s policies and procedures. Osborne and its employees shall conduct all activities in accordance with the highest ethical standards of their respective professions at all times and in a manner which shall uphold Osborne s reputation and standing in the community it serves. E. Confidentiality Osborne and its employees are in possession of, or have access to, a wide variety of confidential and sensitive information. Participant records, including those that contain Protected Health Information (PHI) are the property of the organization and shall be maintained to serve the participant, necessary health care providers, the organization, payers such as Medicare/Medicaid and other third party payers in accordance with legal, accrediting and regulatory organization requirements. The information contained in the health care record belongs to the participant and the participant is entitled to the protection of that information. All participant care information is regarded as confidential and available only to authorized users and employees who may be providing participant care and to third party payers in order to facilitate reimbursement. The operations, activities, business affairs and finances of the organization should also be kept confidential and discussed or made available only to authorized individuals. It is the duty of the organization and its employees to protect the privacy rights of the participants. The organization and its employees shall maintain the confidentiality of participant medical records and information, as well as proprietary information, by actively protecting and safeguarding such information in a manner designed to prevent the unauthorized disclosure of such information. Any use of confidential information must be preceded by appropriately documented consent from the participant. Additional information on safeguarding patient information may be found in Osborne s HIPAA Policy. If there are any questions or concerns regarding the disclosure of information, the question or concern should be referred to an individual s supervisor, the Compliance Office, the Privacy Officer or the CEO. Compliance Program Page 14

15 F. Business Practices Osborne s business practices must be conducted with honesty and integrity and in a manner that upholds the organization s reputation with participants, payers, vendors, competitors and the community. The organization expects its employees to be loyal to the Osborne s interests. Employees should not use their positions to profit personally or to assist others in profiting in any way at the expense of the organization. Employees must refrain from activities which create conflicts of interest with Osborne or which give the appearance of impropriety. Employees involved in business transactions on behalf of the organization shall not offer or pay, or solicit or receive any gifts, favors or other improper inducements in exchange for influence or assistance in a transaction or the referral of business. If there is any doubt or concern about whether specific conduct or activities are ethical or otherwise appropriate, the doubt or concern should be referred immediately to an individual's supervisor, the Compliance Office or the CEO, as appropriate. When Osborne decides to enter into an agreement or arrangement with any entity or practitioner to provide goods or services, that decision must be free of any improper influence. Thus, any employee involved in the decision-making process with respect to such transactions who believes that s/he or a family member may have a significant financial interest in any entity that (i) engages in business or maintains a relationship with the organization, (ii) provides to, or receives from the organization participant referrals, or (iii) competes with the organization, must notify their immediate supervisor and the Compliance Officer so the potential conflict can be reviewed. In this way, the organization can be assured that our business relationships are free from improper influences. For more information, see Conflicts of Interest in the Policy section of this manual. G. Employment Practices Non-discrimination - Osborne provides equal opportunity for employment and advancement to all employees and applicants for employment. Osborne does not discriminate against any individual based on race, creed, ancestry, citizenship status, religion, color, age, national origin, political belief, sexual orientation, gender, gender identity or self-image, gender appearance, behavior or expression, transgender status, marital status, veteran status, disability, prior arrest or conviction history or any other characteristic or status protected by law in employment decisions including recruitment, hiring, compensation, fringe benefits, staff development and training, promotion or transfer, lay-off or termination, or any other condition of employment. Osborne is committed to fostering diversity at all levels. The organization is committed to providing participant care and a workplace environment which emphasizes the dignity and respect of every individual. In that regard, harassment and/or other types of prohibited discrimination in any form or context will not be tolerated. Compliance Program Page 15

16 Environmental Laws - It is the policy of Osborne to comply with all environmental laws and regulations as they apply to the organization's services and operations. Osborne will operate each facility with the necessary permits, approvals and controls and employ proper procedures for handling and disposing hazardous and bio-hazardous waste, including but not limited to medical waste. Drug-free, Smoke-free Workplace - Osborne is committed to providing an efficient, healthy, and safe workplace. Osborne maintains a drug and alcohol free workplace and will not tolerate on its premises the manufacture, dispensation, possession, distribution, or use of illicit drugs or alcohol, or an employee being under the influence of illicit drugs or alcohol. The Osborne workplace must also be one that is free of the effects of smoke-contaminated air; Osborne does not permit smoking anywhere inside its facilities. Violence-free Workplace Osborne and its employees will comply with federal, state and local laws and regulations that promote the protection of health and safety. Violence in the workplace will not be tolerated and such behavior will result in immediate disciplinary action. Employees are expected to report workplace injuries or any situation presenting a danger of injury immediately to their supervisors. For further details concerning the Osborne Freedom from Harassment Policy, Drug-free Workplace Policy, Alcohol Abuse Policy, Smoke-free Workplace Policy and Workplace Violence Prevention Policy see the Osborne Employee Handbook. H. Reimbursement Osborne and its employees have a duty to create and keep records and documentation which conform to legal, professional and ethical standards. Employees involved in delivering reimbursable services, or in billing and reimbursement for services, shall ensure that billings for reimbursement for care are reasonable, necessary and appropriate, that services are provided by properly qualified persons, and that services are billed correctly and supported by adequate documentation. All claims for reimbursement to government and private insurance payers must be true and accurate and conform to all applicable laws and regulations. The organization and its employees are prohibited from knowingly presenting or causing to be presented claims for payment or approval which are false, fictitious, fraudulent or otherwise not in compliance with applicable laws and regulations. I. Administration and Application of this Code of Conduct Osborne expects that the Code of Conduct will be integrated into the daily activities of its employees. The Code of Conduct is in addition to, and does not limit, specific policies and procedures of the organization. Employees must perform their duties in accordance with all such policies and procedures. Compliance Program Page 16

17 It is the duty of all Affected Individuals to uphold the standards set forth in the Code of Conduct and to report violations by following the reporting procedures outlined in the Compliance Manual. Alleged violations of the Code of Conduct or other policies or procedures of the organization will be investigated in accordance with the organization s Compliance Program Policy entitled Investigating Compliance Concerns in this manual. The organization will make efforts to maintain the confidentiality of the identity of any individual who reports perceived or actual violations. However, confidentiality of identity cannot be guaranteed. J. Non- Retaliation It is the duty of all employees to report, in good faith, concerns about actual or potential violations of the Code of Conduct or Compliance Program. Supervisors, managers, and employees are not permitted to engage in retaliation, retribution, intimidation, or any form of harassment directed against an employee who reports a compliance concern. Anyone who is involved in any act of retaliation, retribution or intimidation against an employee that has reported suspected misconduct in good faith will be subject to disciplinary action as described in the Policy section of this manual under Disciplinary Action. For more information, also see the Non-Retaliation, Non-Retribution, and Non-Intimidation for Reporting policy in this manual. K. Violations of the Code of Conduct Adherence to and promotion of the Code of Conduct and Compliance Program will be a factor in evaluating the performance of employees, including supervisory, managerial and administrative personnel. Failure to abide by the Code of Conduct or the guidelines for behavior which the Code of Conduct represents may lead to disciplinary action. Disciplinary action will be determined on a case-by-case basis and may, in the discretion of the organization, range from a warning to termination. If Osborne determines that a violation may have included criminal violations of law or regulation, the organization will seek the advice of counsel and cooperate with law enforcement authorities in connection with any investigation and prosecution of the offender. For more information see Disciplinary Action under the Policy section of this manual. L. Reporting a Violation of the Code of Conduct Employees should report any violation of the Code of Conduct to their immediate supervisor, the Compliance Office, a member of the Compliance Committee and/or via the Ethics Hotline. The Hotline is particularly helpful if you prefer not to report such matter to your supervisor because you believe s/he may be involved in the actual or perceived violation, if you prefer to remain anonymous, if you have a legitimate reason to be concerned about reprisal, or if your previous reports have not been acted upon, but you may use it for any reason. The number of the Ethics Hotline is A compliance report may also be reported to the Hotline via the internet at Hotline reports may be made anonymously, however, supplying your name may assist in the investigation of your report but you are under no obligation to do so. Please note that it is an explicit violation of the policy to Compliance Program Page 17

18 retaliate in any way against an employee who, in good faith, reports an actual or potential violation of applicable laws, rules, regulations, or the Code of Conduct. For details on how to report a violation, please refer to the Compliance Communication in the Policy section of this manual. Please note that nothing in this Code of Conduct is intended to, nor shall be construed as providing, any additional employment or contract right to employees or other persons. Osborne will generally attempt to communicate changes to the Code of Conduct prior to the implementation of such changes. However, the organization reserves the right to modify, amend or alter the Code of Conduct and its policies and procedures without prior notice to any person. Compliance Program Page 18

19 Policies The following policies are part of the Compliance Program of the organization, and are applicable to all Employees (and other Affected Individuals, as indicated in each policy). Policies Page 19

20 Policy Compliance Responsibilities PURPOSE To explain the roles and responsibilities associated with Osborne s Compliance Program. POLICY It is Osborne s the to maintain a Corporate Compliance Office vested with the duties described herein as well as a Corporate Compliance Committee made up of 5-9 members who work closely with the Compliance Office to determine and implement Osborne s compliance strategy and workplan. All Osborne program directors and managers are expected to support the compliance program by setting and enforcing standards within their respective departments and ensuring that staff are trained in Osborne s Code of Conduct and Compliance Program. Policies Page 20

21 Compliance Committee The Compliance Committee shall consist of approximately 5-9 members of the organization, appointed by the President/CEO or Chief Compliance Officer, meeting at least semi-annually and shall include: Chief Compliance Officer and any other members of the Compliance Office Member(s) of Management Member(s) of the Human Resources Department Member(s) of the Quality Review/Grants Management Department Members of the Program Operations Departments Member(s) of the Finance Department Duties 1. Advise the Compliance Office and assist in the implementation and maintenance of the Compliance Program; 2. Determine the appropriate strategy and/or approach to promote adherence to the Compliance Program and the detection of potential violations; 3. Maintain a system to solicit, evaluate, and respond to complaints and problems; 4. Oversee the education and training of employees and systems for communication with and by employees; 5. Establish confidentiality standards and requirements for committee members and those persons requested to provide assistance to the committee. The Compliance Committee may adopt written guidelines for holding meetings and conducting the activities, and for operations of the committee. Vacancies. Any vacancy on the committee, whether by resignation, illness, death or otherwise, shall be promptly filled by appointment by the President/CEO or Chief Compliance Officer and each such appointee shall serve for the remainder of the unexpired term of his or her predecessor. A summary of the activities of the Committee shall be reported to the Board of Directors at least annually. Corporate Compliance Office The President/CEO shall appoint the Chief Compliance Officer who shall report to the President/CEO and the Board of Directors. The Chief Compliance Officer may also appoint one or more Deputy Compliance Officers who shall report to the Chief Compliance Officer. The Policies Page 21

22 Chief Compliance Officer and any Deputy Compliance Officers will constitute the Compliance Office. The Chief Compliance Officer will be responsible for overseeing the administration and implementation of the Compliance Program and will report at least annually to Board of Directors about Compliance Program operations. The Chief Compliance Office will seek advice from outside legal counsel when appropriate. The Chief Compliance Officer shall be the Designated Employee with Vested Compliance Responsibility as per the section Required Elements of the Compliance Program, above in this Manual. The Chief Compliance Officer acts as staff to the President/CEO and Board of Directors by monitoring and reporting results of the compliance and ethics efforts of the organization and in providing guidance for the Board and senior management team on matters relating to compliance. The Chief Compliance Officer, together with the Compliance Committee, are authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program. The Compliance Office shall have access to all documents and information relevant to compliance activities including but not limited to participant records, billing records, human resources records, marketing records, and contracts and written arrangements or agreements with others. Primary Responsibilities of the Chief Compliance Officer (assisted by the Deputy Compliance Officer, if applicable): 1. Serve as chairperson of the Compliance Committee and supervise the implementation and day-to-day operations of the Compliance Program (or delegate this role to a Deputy Compliance Officer under supervision of the Chief Compliance Officer); 2. Develop, implement, and periodically update an effective Code of Conduct and Compliance Program, at intervals determined by the Chief Compliance Officer, to prevent illegal, unethical, or improper conduct. The policies therein shall establish standards of conduct, clearly identify prohibited conduct, provide for monitoring of compliance activities, and establish mechanisms by which prohibited conduct will be reported to the Compliance Office. 3. Develop such new policies and procedures as may be required to address areas of high risk of noncompliance. 4. Establish and coordinate a regular compliance training process about relevant compliance issues; develop subject-specific training on regulatory requirements related to department functions if necessary and document the training Policies Page 22

23 administered to ensure that all appropriate employees are knowledgeable about the compliance issues that pertain to them. 5. Assist supervisory staff to establish multi-level mechanisms (including periodic audits) to monitor compliance with the standards set forth in Compliance Policies and document implementation and results. 6. Implement and oversee the development of a confidential system for employees and others to seek guidance on business conduct and to report suspected violations of law, compliance standards or other policies and procedures. 7. Independently investigate and act on matters related to compliance, including the design and coordination of internal investigations that respond to reports of problems or suspected violations. 8. Implement and monitor an anonymous hotline as a mechanism to receive concerns without fear of retaliation and review problem areas identified by callers. 9. Consistently enforce policies and procedures through appropriate interventions and/or disciplinary or other corrective action in conjunction with legal counsel when appropriate. 10. Propose modifications to the Compliance Program, as necessary, to prevent recurrence of problem 11. Conduct a regular review of the Compliance Program s functioning and prepare periodic and annual reports for the Board of Directors describing the compliance efforts undertaken during the preceding year, identifying any changes necessary to improve the Compliance Program. 12. Prepare evaluation reports on compliance activities, including reports or complaints received from employees, investigations, and audits and monitoring, to be presented to the Board, President/CEO, and the Compliance Committee on a regular basis, at intervals determined by the Compliance Office. Reporting to the Board shall be done at least annually. 13. Report all financial, operational and compliance related investigations, at least semiannually, to the organization s Chief Executive Officer. 14. Coordinate reviews and audits under the Corporate Compliance Plan utilizing the Office of the Medicaid Inspector General s Compliance Program Work Plan Guidance, including a risk assessment of areas by departments and incorporation of risks identified into a work plan, periodically, at intervals determined by the Chief Compliance Officer. Policies Page 23

24 15. Respond, in conjunction with Legal counsel where necessary, to external organizations requests regarding compliance issues. Policies Page 24

25 Program Directors and Managers Each program director or manager shall be responsible for the following aspects of the Compliance Program: 1. Implementing and maintaining compliance standards and policies and procedures specific to their program or department and such additional compliance measures as necessary for the business units they oversee, consistent with the Compliance Program and subject to the approval of the Compliance Office. 2. Ensuring that all employees have received training as prescribed by the Compliance Program, including compliance standards, policies, procedures, laws and regulations applicable to employees of the department as directed by the Compliance Office; 3. Enforcing this Compliance Program and the Code of Conduct, the organization s policies and procedures, and applicable laws and regulations as directed by the Compliance Office; 4. Cooperating with any investigation initiated under the Compliance Program as directed by the Compliance Office consistent with the Policy entitled Investigating Compliance Concerns; 5. Reporting to the Compliance Office any reports or reasonable indication of violations of applicable law or regulation by any employee; 6. Initiating and/or implementing corrective or disciplinary action as determined by the Chief Compliance Officer, in consultation with HR if deemed appropriate, following an Investigation initiated pursuant to the Compliance Program or otherwise appropriate and as necessary for the operation of the department; and 7. Taking all measures reasonably necessary to ensure compliance with this Program and applicable laws and regulations as directed by the Compliance Office. Policies Page 25

26 Policy Compliance Training and Education PURPOSE To provide guidance on the training of all Affected Individuals about their duties and obligations under the Compliance Program and Code of Conduct. Training shall include compliance issues, expectations and the operation of the compliance program. Training is required to provide all Affected Individuals with the knowledge and skills to carry out their responsibilities in compliance with all requirements, including those relating to the delivery of healthcare and billing for services, in a manner consistent with applicable laws and regulations. POLICY A. Initial Training. All new employees will receive a hiring package that includes, at a minimum, an overview of fraud and abuse laws, a presentation on the importance of coding and billing issues (if relevant to their position), a summary of the standards of conduct highlighting the agency commitment to integrity in its business operations and compliance with applicable laws and regulations, and an explanation of the elements of the Compliance Program, including the complaint or reporting process. All new members of the governing body will receive an overview of the Compliance Program that is appropriate for their role. B. Ongoing Training. All employees and members of the governing body will be trained in the following areas at least every two years: i. the organization s Compliance Program; ii. the consequences both to the organization and to individuals of failing to comply with applicable laws and regulations. Such training must emphasize the importance of the Compliance Program and the commitment to honesty and integrity in its business dealings. C. Substantive Rules. All individuals involved in the delivery of or billing for the organization's health related services, will be trained and, as necessary, retrained in the specific federal and other health care program rules (e.g. Medicare/Medicaid) that relate to their particular job functions. This training will include, but not be limited to the following types of training: i. Intake Staff will receive training regarding their role in obtaining the necessary demographic, insurance and other information to support proper authorization for services. ii. Billing Staff will receive training in the fraud and abuse laws as they relate to the claim development and submission process and business relationships, as well as relevant Medicare and Medicaid other federal and state requirements. Policies Page 26

27 iii. iv. Providers of Care will receive training that includes clinical documentation requirements, medical necessity considerations, and confidentiality of participant information, and other training regarding their activities affecting the claim submission process. Financial and other administrative management personnel will receive training applicable to their role. D. Tailoring of Training To Role. i. All employees and members of the governing body shall receive minimum training sufficient for compliance with the Compliance Program and Code of Conduct, as determined by the Chief Compliance Officer. ii. Additional tailored training shall be given to employees as necessary to perform their job functions in a manner consistent with the Compliance Program. The contents of such additional training shall be determined based on the risk areas or areas of concern associated with each job function, subject to approval by the Compliance Officer. E. Methods of Training. Training and education may occur in sessions with individual employees, in mandatory in-service meetings, via webinar, or incorporated into special or regular departmental meetings or in some other effective manner. Training may consist of live presentations, videos, question and answer sessions and written material and may occur in-house or through attendance at external workshops and seminars, through online webinars or other means determined appropriate by the Chief Compliance Officer. F. Frequency of Training. Training shall occur for all employees at orientation and at least every two years thereafter. Following any incident or violation of the Compliance Program, additional training may be provided at the discretion of the Chief Compliance Officer. G. Documentation. The training provided to employees shall be documented. The documentation shall include the date and a brief description of the subject matter of the training activity or program and the names of those attending. Documentation is important and will be retained on file for a minimum of seven (7) years. H. Failure to Attend. Failure to comply with training requirements or to attend scheduled training sessions of the agency or required trainings of any department may result in disciplinary action. I. Evaluation. The Compliance Office shall conduct informal debriefs/evaluations of training and education programs to determine, and if necessary improve, the value, effectiveness and appropriateness of any such program Policies Page 27

28 Policy Compliance Communication PURPOSE To provide guidance on the open communication necessary to maintain an effective compliance program and reduce any potential for fraud, abuse and waste. Any actual or perceived communication problem should be reported to Management, Human Resources, or the Compliance Office. POLICY A. Questions. At any time any Affected Individual may seek clarification or advice from the Compliance Office in the event of any confusion or question with regard to this Program or any element of this Program or any organizational policy or procedure related to this Program. Questions and responses should be documented and, if appropriate, shared with employees or other Affected Individuals as appropriate for informational and educational purposes. To facilitate such communication, the Compliance Office and Compliance Committee shall make publicly available their contact information, including names, locations, phone numbers and addresses. B. Reporting. All Affected Individuals are required to report violations of the Compliance Program, or acts of fraud, abuse, or waste of which they are aware or reasonably suspect. An employee who for any reason is uncomfortable reporting a suspected violation to any of the above-referenced individuals may do so confidentially or anonymously using the Ethics Hotline. All reports of suspected violations will be treated confidentially. The organization will promptly and thoroughly investigate any suspected violation in as confidential manner as possible, and take appropriate disciplinary action if warranted. C. Reporting Lines Of Communication for Compliance Questions and Reports 1. To Supervisor. All employees may, but are not required to, report to their supervisor or department director or manager. If a supervisor or manager receives such a report, he or she will promptly pass on the report to the Chief Compliance Officer or Deputy or member of the Compliance Committee. 2. To Compliance Personnel. All Affected Individuals may report directly to the Compliance Office or to a member of the Compliance Committee. 3. Via Hotline or Website. All Affected Individuals may anonymously file reports on Osborne s anonymous Ethics Hotline using one of the following methods at any time: i. Via the web at ii. Via toll-free telephone call at (866) Policies Page 28

29 The above anonymous reporting methods shall be posted in various locations throughout the organization s facility. All Affected Individuals will be made aware of their duty to report violations and the availability of these anonymous reporting methods. 4. To OMIG. All Affected Individuals may also call the hotline of the Office of the Inspector General of the Health and Human Services Department, HHS-TIPS ( ) the NYS Office of Medicaid Inspector General Compliance main line at or the Fraud Hotline at FRAUD. The Compliance Office will post this number in prominent locations in the organization. D. Confidentiality. Reports received will be treated confidentially to the extent possible under applicable law. However, there may be instances when an individual s identity may become known or must be revealed. For example, if governmental authorities become involved, in response to subpoena or other legal proceeding, or if the matter cannot be fully investigated without the possibility of identifying information about the reporter. E. Non-Intimidation and Non-Retaliation. All disclosures under this policy are subject to Osborne s Policy on Non-Retaliation, Non-Retribution and Non Intimidation for Reporting, contained in this manual. F. Documentation. The Chief Compliance Officer and Deputy Compliance Officer shall maintain a record of reports of violation of this Program, or of the standards of conduct, or of relevant law or regulations, received by the Compliance Officer. The Chief Compliance Officer and Deputy Compliance Officer shall periodically, at intervals determined by the Chief Compliance Officer, furnish a summary of such reports to the President/CEO, the Compliance Committee and the Audit/Finance Committee of the Board of Directors. Policies Page 29

30 Policy Identifying & Investigating Compliance Concerns PURPOSE To provide guidance on the requirements for identifying, and investigating alleged fraud, waste, or abuse, and other compliance concerns. To describe the activities that should be performed to ensure proper investigation of any reported and non-reported concerns. This policy also articulates the expectations for assisting in the resolution of compliance issues for all Affected Individuals. POLICY Osborne s Compliance Program shall include routine self-evaluation, risk assessment, internal audit and other activities designed to identify compliance risk areas specific to the organization as well as a process for investigating and addressing potential or actual non-compliance as a result of these self-evaluations and audits. Routine Identification of Risk Areas Regardless of whether a complaint or other concern has been received, the following Compliance Investigation activities shall occur on an annual basis except where noted below: Completion of OMIG Assessment form; Certifying at year-end to the Office of the Medicaid Inspector General; Practitioner Credentialing; Risk Assessment (at intervals determined by the Chief Compliance Officer); Annual completion of the Medicaid Billing Self-Assessment tool for a random sample of Medicaid claims Review of a random sample of Medicaid claims at least quarterly using Federal OIG guidelines Updating of the Medicaid Compliance Work Plan. Investigations. Investigations conducted pursuant to the Compliance Program shall be conducted with the following goals: To identify situations in which there is reasonable cause to believe applicable federal and state laws, including those related to Medicare and Medicaid programs, or Osborne policies, may not have been followed; To identify individuals who may have knowingly or inadvertently violated the law or the Osborne policies; To facilitate the correction of any violations or misconduct; To implement procedures necessary to ensure future compliance; To protect the organization in the event of civil or criminal enforcement actions; and/or To preserve and protect the assets of the organization. A. Requirement for Program Directors and Managers to Report Violations. Each manager and program director is responsible for promptly reporting any incident reasonably believed to be a violation of the Compliance Program, Code of Conduct, other policy of Policies Page 30